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Medi-Cal Share of Cost. Randolph T. Boyle Staff Attorney California Medicare Coalition Webcast April 9, 2008. What is a “Share of Cost (SOC)?”. Spending down monthly income in order to qualify for Medi-Cal under the Medically Needy or Medically Indigent programs

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Medi-Cal Share of Cost

Randolph T. Boyle

Staff Attorney

California Medicare Coalition

Webcast

April 9, 2008


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What is a “Share of Cost (SOC)?”

  • Spending down monthly income in order to qualify for Medi-Cal under the Medically Needy or Medically Indigent programs

  • Similar to a deductible, but no insurance until it is met.

  • Not like a premium--not a monthly debt to be paid

  • County notice of action will show the amount of the SOC


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How is SOC determined?

Countable

Income – Medically Needy Level = SOC

First apply deductions and exemptions to income

E.g. $20 any income disregard, payments for health care premiums

Medically Needy Income Levels (MNL, MNIL) have stayed the same since 1989


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What is “meeting” a SOC?

  • The beneficiary must incur that amount of medical expenses in the month before Medi-Cal will begin to pay.

  • The SOC need not be paid, only incurred

  • How and whether the medical expenses are paid for is between the beneficiary and the provider


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How does someone meet the SOC?

  • When a beneficiary uses the Medi-Cal card for medical services

    • Only for current services

  • Taking bills to the Medi-Cal eligibility worker at the county office

    • May apply old bills to this month or a previous month’s SOC


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Using Old Bills to Satisfy a SOC

  • Paid bills

    • May only apply to the month in which they are incurred and paid

  • Unpaid bills

    • Must still be owed

    • Must have a bill dated within 90 days

      • May be a reissued bill

    • Credit card statements—must show all of them since the debt first appeared

    • Sworn statements


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Whose bills can be used?

  • The beneficiary’s medical expenses

  • A dependent family member’s expenses

  • Bills for services received before getting on Medi-Cal


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What kind of medical expenses can be used?

  • Medi-Cal covered services

  • Services that Medi-Cal would cover, but are beyond the amount, duration or scope of Medi-Cal.

  • Services that Medi-Cal does not cover

  • Cost sharing, such as from Medicare, and other health insurance premiums, deductibles, and co-payments

  • When applying these to a person’s SOC, apply in the reverse order of what is listed above


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How can someone avoid a SOC?

  • Most Medi-Cal programs and most beneficiaries do not have a SOC

  • Look at eligibility under another Medi-Cal program

    • Aged & Disabled Federal Poverty Level (FPL) Program

    • 250% Working Disabled Program

    • Pickles (people who lost SSI due to a COLA)

    • Medi-Cal Waivers


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SOC and Managed Care

  • Generally, people with only Medi-Cal with a SOC are not enrolled into a Medi-Cal managed care plan

    • Except in County Organized Health System (COHS) counties

  • Dual eligibles may enroll in Medicare Advantage plans or Special Needs Plans (SNPs)

    • However, some SNPs will allow people to stay in the SNP when they do not meet their SOC while others will not


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Medi-Cal Share of Cost and Medicare Part D

  • A Medi-Cal beneficiary with a SOC may receive the full LIS if:

    • She meets her SOC in one month; or

    • She completes an application for LIS and is approved for LIS.


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Meeting SOC and Getting LIS

  • If the beneficiary meets her SOC once January-June:

    • She gets the full LIS with the lowest co-payments for that month and the rest of the calendar year

  • If the beneficiary meets her SOC once July-December

    • She gets the full LIS with the lowest co-payments for that month and the rest of the calendar year AND all of the next calendar year


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Questions?

Randy Boyle

Staff Attorney

National Health Law Program

(310) 204-6010, ext. 108

[email protected]

www.healthlaw.org

www.healthconsumer.org


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